Source · CQC inspection

St Helier Hospital and Queen Mary's Hospital for Children

Provider Epsom and St Helier University Hospitals NHS Trust Type NHS Healthcare Organisation Region London Last inspected 11 Jun 2026

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Good

Well-led

Requires Improvement

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 11 June 2026

The service is not performing as well as it should and we have told the service how it must improve.

Date of assessment: 02 and 03 December 2025. St Helier Hospital and Queen Mary's Hospital for Children is part of Epsom and St Helier University Hospitals NHS Trust and provides a range of NHS hospital services to people living in Southwest London and neighbouring areas. This assessment looked at maternity services, medical care, surgery and urgent and emergency care to assess the quality of the care received by patients using those services. The rating of maternity service, medical care, surgery and urgent and emergency care have been combined with the …

Ratings by service

Maternity

Good

Jul 2025

Medical care (Including older people's care)

Good

Jul 2025

Surgery

Requires Improvement

Jul 2025

Urgent and emergency services

Requires Improvement

Jul 2025

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (2)

Breach Caring

The service was in breach of legal regulation in relation to Regulation 10, Dignity and Respect, Regulation 12, Safe Care and Treatment, and Regulation 15, Premises and equipment, Health, and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regulation: Regulation 10 (Dignity and respect) · 11 Jun 2026

Breach Well-led

At this assessment we found a breach of regulation in relation to good governance.

Regulation: Regulation 17 (Good governance) · 11 Jun 2026

Earlier inspection findings

pre-2024 framework · 10 must-do 4 should-do

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10

Must do

Safe

The service must ensure all staff are up to date with maternity mandatory and safeguarding training modules.

Regulation: Regulation 12(1)(2)(c)

⚠ Not all anaesthetic staff had completed the required mandatory training. Not all staff had training on how to recognise and report abuse, with only 39% of doctors completing level 3 safeguarding adults training and 68% completing level 3 safeguarding children.

Must-do action 2 of 10

Must do

Safe

The service must ensure premises and equipment are secure, suitable and properly maintained.

Regulation: Regulation 15(1)(b)(c)(e)

⚠ The environment in some areas was not fit for purpose, with peeling paintwork and damp mould on the wall in the induction of labour bay, and broken ceramic tiles and ingrained graffiti in the visitor’s toilet. The bereavement room was not soundproof and had damaged frosting on its door. The …

Must-do action 3 of 10

Must do

Safe

The service must ensure it assesses and mitigates risks to women, birthing people and babies.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not consistently complete nor update risk assessments and did not always take action to remove or minimise risks. Staff did not always identify and quickly act upon women and birthing people at risk of deterioration. Resuscitaires required for emergency treatment of newborns were out of service date and …

Must-do action 4 of 10

Must do

Safe

The service must operate clear triage processes to ensure the safety of women, birthing people, and babies.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ The process for women attending maternity assessment unit (MAU) or triage was unclear, with no clear or written guidance for staff on when women and birthing people should be directed to triage or MAU. This lack of clarity put women and birthing people at risk, including one patient who was …

Must-do action 5 of 10

Must do

Safe

The service must ensure medical staffing for maternity triage is reviewed so there are sufficient numbers of staff to review women and birthing people in a timely manner.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ The service did not have enough medical staff deployed to maternity assessment unit and triage to ensure women and birthing people were seen in a timely way, leading to delays in doctors attending triage and MAU to review women and birthing people.

Must-do action 6 of 10

Must do

Safe

The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk of deterioration.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not consistently fully complete Modified Early Obstetric Warning Scores (MEOWS). Audits showed at least one of every five MEOWS records were incomplete, meaning deterioration of a woman or birthing person’s health may be missed and not escalated.

Must-do action 7 of 10

Must do

Safe

The service must ensure that staff caring for transitional care babies have the appropriate level of qualifications and additional training.

Regulation: Regulation 18(1)(2)(a)

⚠ Staff caring for transitional care babies did not have the qualification and competence for the role they were undertaking. The transitional care bay was staffed by a maternity support worker and midwife with no neonatal nurse presence, which was not in line with British Association of Perinatal Medicine guidance.

Must-do action 8 of 10

Must do

Safe

The service must ensure the role of recovery practitioner is role is carried out by staff with the right level of qualification and additional training.

Regulation: Regulation 18(1)(2)(a)

⚠ Staff supporting women or birthing people following a caesarean section had not been trained to the same standard as for all recovery practitioners working in other areas of general surgical work, which was not in line with Royal College of Anaesthetist guidelines.

Must-do action 9 of 10

Must do

Safe

The service must ensure records of the care and treatment provided are accurate, complete and contemporaneous.

Regulation: Regulation 17(1)(2)(c)

⚠ Inconsistencies were found in the completion of care records, including missing risk assessments, test results (e.g., carbon monoxide monitoring, blood tests), and inaccurate records of actual care provided. Audits also identified omissions such as missing swab counts and 'fresheyes' reviews of cardiotocography monitoring.

Must-do action 10 of 10

Must do

Well-led

The service must ensure it operates effective systems and processes to maintain clear oversight of maternity services and enable it to assess, monitor and improve the quality and safety of services and mitigate risks to women, birthing people and babies.

Regulation: Regulation 17(1)(2)(a)(b)

⚠ Leaders did not operate effective systems and processes nor have clear oversight of maternity services. Local governance systems did not effectively identify risks and issues, and systems to ensure emergency equipment was checked and safe for use were not effective. The leadership team did not take timely action to make …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4

Should do

Safe

The service should continue to ensure the design and maintenance of the environment allows staff to detect, prevent and control the risk of the spread of infection.

Should-do action 2 of 4

Should do

Safe

The service should ensure ‘fresheyes’ checks of cardiotocography (fetal heart rate) monitoring are carried out hourly.

Should-do action 3 of 4

Should do

Safe

The service should ensure staff use the ‘situation, background, assessment, recommendation’ handover format when handing over care of women, birthing people and babies.

Should-do action 4 of 4

Should do

Well-led

The service should ensure midwifery staff complete an annual appraisal.